程序化撤机

程序化撤机哈医大二院魏文举脱机=SBT≈拔管原发病得到控制降低呼吸机支持力度SBT试验评估气道保护能力拔管（discontinuationandweaningfrommechanicalventilation）延迟撤机excessstay增加住院时间iatrogeniclunginjury医源性的肺损伤unnecessarysedation不必要的镇静highermortality更高的死亡率过早撤机musclefatigue呼吸肌肉的疲劳dangerousgasexchangeimpairment气体交换障碍lossofairwayprotection失去气道保护ahighermortality更高的死亡率一次失败的拔管使患者得VAP的机率增加8倍，死亡风险增加6~12倍！！！•Indeed,afailedextubationisassociatedwithan8-foldhigheroddsratiofornosocomialpneumoniaanda6–12-foldincreasedmortalityrisk.EpsteinSK,CiubotaruRL,WongJB.Effectoffailedextubationontheoutcomeofmechanicalventilation.Chest1997;112(1):186-192.再插管率一般为4%-23%，但有精神状态变化和神经损伤的患者再插管率更高•Reportedreintubationratesrangefrom4%to23%fordifferentICUpopulations,andmaybeashighas33%inpatientswithmentalstatuschangesandneurologicimpairment.FagonJY,ChastreJ,HanceAJ,MontraversP,NovaraA,GibertC.Nosocomialpneumoniainventilatedpatients:acohortstudyevaluatingattributablemortalityandhospitalstay.AmJMed1993;94(3):281-288.First需求能力VSSecond•Thesecondfundamentalreasonthatpatientsareunabletobewithdrawnisclinicianbehavior.•临床医生不能及时的去找准拔管时机，甚至拖延拔管。主要通过不当的呼吸机设置，不当得镇静与肌松药的应用，营养不良。1999年，麦克马斯特大学从全世界5000多篇关于脱机程序的文献总结了一篇综合性的文献。找出能够判断脱机时机的66个标准，为了评估这些参数的有效性，麦克马斯特大学使用了似然比总结了7个最有效的成功脱机机指标。Po.1敏感性：87%特异性：66%f/Vt敏感度：65~90%特异性：0~36%好转的指标：？？？However,havebeenneitherdefinednorprospectivelyevaluatedinarandomizedcontrolledtrial.Rather,variouscombinationsofsubjectiveassessmentandobjectivecri-teria(eg,usuallygasexchangeimprovement,mentalsta-tusimprovement,neuromuscularfunctionassessments,andradiographicsigns)thatmayserveassurrogatemarkersofrecoveryhavebeenemployed。主观评估+客观标准•Althoughthereneedstobesomeevidenceof“clinical”stability/reversal,amorefocusedassessmentisneededbeforedecidingtocontinueordiscontinueventilatorysupport.TheACCP/SCCM/AARCguidelinesstatethatthisformalassessmentshouldbeanSBT.美国胸科医师学院，危重症病学院，呼吸治疗学会都认为SBT是最有针对性的评估指标。SBTsT-piecePSVCPAPThepercentageofpatientswhoremainedextubatedafter48hwasnotdifferentbetweenthetwogroups(63%T-tube,70%pressuresupportventilation,p=0.14).PSV的成功率比T管高，但48h后的拔管成功率没有统计学差异！ExtubationoutcomeafterspontaneousbreathingtrialswithT-tubeorpressuresupportventilation.TheSpanishLungFailureCollaborativeGroup.AmJRespirCritCareMed.1997Aug;156(2Pt1):459-65.T-pieceapproachmightbeconsideredifthereisconcernaboutborderlineSBTperformancewithothertechniques危险？Indeed,inacohortof1,000patientsinwhomSBTswereroutinelyadministeredandproperlymonitoredaspartofaprotocol,onlyoneadverseeventwasthoughttobeevenpossiblyassociatedwiththeSBT.ElyEW,BakerAM,EvansGW,HaponikEF.Theprognosticsig-nificanceofpassingadailyscreenofbreathingspontaneously.IntCareMed1999;25(6):581-587.SBT失败患者的处理1）给一个合理的舒适的呼吸机支持条件，切忌过分消减呼吸机的支持力度。2）积极寻找病因，逆转后再次评估，24小时后再次进行SBT。PMV患者的脱机策略超过28天继续机械通气的患者。PMVpatientsareestimatedtobeasmanyas5–10%ofallmechanicallyventilatedpatientsintheUnitedStates.Whilein-patientmortalityinPMVpatientsmaybeashighas35%,asmanyashalfofthesurvivorswillbesuccessfullywithdrawnfrommechanicalventilatorsup-port,usuallywithinthefirst90days.Thereafter,thelikelihoodofsuccessfulventilatorwithdrawalisverylow.MacIntyreNR,EpsteinSK,CarsonS,ScheinhornD,ChristopherK,MuldoonS.Managementofpatientsrequiringprolongedmechanicalventilation.Chest2005;128(6):3937-3954终止每日SBT,恢复机械通气，然后逐渐减少支持力度，当支持力度减少到初始的50%时，重启SBT。SBT时间不再是30-120min，根据患者的耐受成都逐渐延长，直至在清醒的时候完全自主呼吸，最后在睡眠的过程中也是SBT。.MacIntyreNR,EpsteinSK,CarsonS,ScheinhornD,ChristopherK,MuldoonS.Managementofpatientsrequiringprolongedmechanicalventilation.Chest2005;128(6):3937-3954脱机能否自动化？呼吸机的新进展提供了很多新的呼吸模式，但是自动化呼吸机撤机缺乏对病人的变量，是仅仅依靠潮气量和分钟通气量，所以使用的潜力比较有限。Iftheseautomatedsystemshaveanyutility,itwouldmostlikelybeeitherinthesettingofarapidlyrecoveringpatientinanICUorperhapsduringthegradualrecoveryprocessofthePMVpatient,asdescribedabove.镇静药的最少化SAT+SBT评估气道保护能力有无上呼吸道的梗阻气囊漏气实验阳性3次最小漏气的平均值110ml处理激素24h之前给，排除气管插管周围被有滞留物附着。有效咳嗽能力咳嗽的峰流速160L/min完整的认知能力？？脑部损伤、昏迷的患者GCS评分8的患者能够成功脱机KingCS,MooresLK,EpsteinSK.Shouldpatientsbeabletofollowcommandspriortoextubation?RespirCare2010;55(1):56-65.气管造口术的作用优势：更舒适，减少镇静药的使用；存在吞咽反射，可以吃饭；减少感染；降低气道阻力….劣势：有创操作，并发症多：皮下气肿、气胸及纵隔气肿；出血；感染；气管狭窄和软化….早切VS晚切EarlytracheostomiesDelayedtracheostomymortality31.7%61.7%pneumonia5%25%accidentalextubations06timeonMV7.6+/-2.017.4+/-5.3timeinICU4.8+/-1.416.2+/-3.8Aprospective,randomized,studycomparingearlypercutaneousdilationaltracheotomytoprolongedtranslaryngealintubation(delayedtracheotomy)incriticallyillmedicalpatients.RumbakMJ1,NewtonM,TruncaleT,SchwartzSW,AdamsJW,HazardPB.CritCareMed.2004Aug;32(8):1689-94小结脱机是个过程而不是动作过早过晚都不行“金标准”并非金标准，还得加上主观判断SBT最好还是T管脱机自动化？SAT+SBT…..气道保护能力不能忘（神志影响？）还是早切好！！Thankyou